Otolaryngology & Family Medicine & Head and Neck Surgery
Dysphonia (hoarseness)
Dysphonia refers to any qualitative or quantitative alteration of the voice - change in timbre (hoarse, raspy, veiled, blown), pitch (abnormal low or high voice), intensity (dead voice, partial aphonia) or vocal endurance (rapid vocal fatigue) - compared to the person's usual voice. Hoarseness is the most frequent and recognizable manifestation. Voice production relies on the vibration of the vocal cords (vocal folds) as exhaled air passes through: any structural, inflammatory, neurological or functional lesion that alters the morphology, flexibility or mobility of the vocal cords can cause dysphonia. Dysphonia is an extremely frequent symptom in clinical practice - its instantaneous prevalence is estimated at 1 % of the general population, with a lifetime prevalence of 30 % - and is a major reason for consultation among voice professionals (teachers, singers, actors, lawyers, telephone operators), who represent around 25 % of the working population. The vast majority of acute dysphonias are benign and transient (viral or acute laryngitis - spontaneous resolution in 1-2 weeks). On the other hand, dysphonia persisting beyond 2-3 weeks with no obvious cause should systematically lead to laryngoscopy to visualize the vocal cords and rule out a neoplastic lesion (laryngeal cancer - of which squamous cell carcinoma is the main form): smoking is the major risk factor, and persistent dysphonia in a smoker is laryngeal cancer until proven otherwise. Laryngeal cancer accounts for 25-30 % of cancers of the upper aerodigestive tract (UADT) - 5,000 new cases/year in Canada - with an excellent prognosis in the early stages (5-year survival >90 % for T1-T2) if detected early.
Causes of dysphonia - classification
| Cause | Mechanism and clinical presentation | Diagnosis and treatment |
|---|---|---|
| Acute viral laryngitis Most frequent cause |
Upper respiratory viral infection (rhinovirus, adenovirus, influenza, RSV, SARS-CoV-2) → edema and inflammation of the laryngeal mucosa and vocal cords → thickening of the vocal folds → dysphonia or aphonia; context: flu-like syndrome or rhinopharyngitis in the preceding days; hoarse, raspy, painful voice with use; mild odynophagia; dry, irritative cough; usual duration: 7–14 days with spontaneous resolution | Clinical Diagnosis — laryngoscopy not necessary if resolution in <3 weeks; Treatment: strict vocal rest (whispering worsens vocal cord strain — absolutely avoid); ample hydration (mucosal humidification); steam inhalations; avoid alcohol, tobacco, caffeine (mucosal drying); NSAIDs or paracetamol if odynophagia; corticosteroids (dexamethasone 10 mg IM single dose) if professional aphonia requiring rapid recovery — occasional use justified in voice professionals |
| Laryngopharyngeal reflux (LPR) Frequently unrecognized cause |
Acidic and/or non-acidic gastric content reflux (pepsin, bile acids) up to the larynx and pharynx → chronic chemical irritation of the laryngeal mucosa → erythema of the arytenoids and laryngeal margin, subglottic edema (pseudomembrane) → chronic dysphonia + muffled voice in the morning + chronic throat clearing + nocturnal dry cough + pharyngeal globus (sensation of a foreign body in the throat); LPR can exist without pyrosis or regurgitation (60–70 % of cases) — which clinically distinguishes it from classic GERD; increasing incidence, likely favored by obesity and late meals | Ambulatory high-resolution pH monitoring (with pharyngeal probe positioned at the level of the upper esophageal sphincter) — gold standard; RSI (Reflux Symptom Index >13 — suggestive); laryngoscopy (arytenoid erythema and edema, subglottic pseudomembrane); treatment: double-dose PPI (omeprazole 40 mg × 2/day) for 3–6 months (response to treatment can itself confirm the diagnosis); lifestyle and dietary measures (elevate head of bed 15–20 cm, avoid meals 3 hours before bedtime, reduce alcohol, coffee, acidic foods); alginate antacids (Gaviscon) after meals and at bedtime |
| Vocal cord nodules Voice Professionals |
Bilateral symmetric benign lesions located at the junction of the anterior and middle thirds of the vocal folds (maximum vibration zone – nodal contact point) → result from repeated chronic vocal trauma (vocal abuse, poor vocal technique); high prevalence in teachers (30–40 %), professional singers, children (childhood nodules – «screamer's nodules»); hoarse, breathy voice with rapid vocal fatigue; symptoms worsen at the end of the day after intensive vocal use; nodules are generally bilateral (unlike polyps, which are unilateral) | Laryngoscopy with laryngeal stroboscopy (visualization of bilateral nodules + mucosal wave analysis) - gold standard exam; treatment: speech therapy (first-line treatment - correction of poor vocal technique + vocal hygiene + voice exercises); 80-90% success % with compliance; microlaryngosurgery (suspension microsurgery under general anesthesia - nodule resection with CO2 laser or microinstruments) if speech therapy failure ≥6 months or fixed fibrous lesions; relative vocal rest (not strict - counterproductive to speech therapy training) |
| Vocal cord polyp | Benign lesion, most often unilateral (unlike nodules) - pedunculated or sessile - resulting from an episode of acute vocal strain or scarred intracordal hemorrhage; chronic hoarse voice, sometimes with vocal diplopia (two simultaneous sounds); the polyp can become secondarily infected (ulcerated polyp); risk factors: smoking, intense sudden vocal effort (shouting, coughing) on fragile mucosa | Laryngoscopy with stroboscopy (pedunculated unilateral polyp visible); standard surgical treatment (laryngeal microsurgery — resection with microinstruments or CO2 laser) — indispensable postoperative speech therapy (prevention of recurrence); mandatory smoking cessation |
| Laryngeal cancer Absolute red flag — smoker >2-3 weeks |
Carcinome épidermoïde (95 % des cas) — les formes glottiques (cordes vocales) sont les plus fréquentes (60–65 %) et les plus précocement symptomatiques (dysphonie dès le stade T1) ; les formes supraglottiques (épiglotte, bandes ventriculaires) et sous-glottiques sont souvent diagnostiquées plus tardivement (dysphagie, adénopathie cervicale) ; facteurs de risque : tabagisme (×10–15 risque) + alcool (effet synergique multiplicateur) + HPV 16/18 (surtout supraglottique) ; voix rauque progressive, persistante, ne s'améliorant pas ; odynophagie, dysphagie, otalgie réflexe (douleur irradiant dans l'oreille), stridor (stade avancé), adénopathie cervicale ; hémoptysie (rare) | Indirect laryngoscopy (laryngeal mirror or flexible nasofiberscopy) → direct laryngoscopy under general anesthesia with multiple biopsies — diagnostic gold standard; cervicothoracic CT scan with contrast (local extension, adenopathy, pulmonary metastases) + FDG-PET scan if advanced stage; treatment: T1–T2 glottic — exclusive radiotherapy (70 Gy over 7 weeks) or conservative surgery (transglottic endoscopic CO2 laser cordectomy) — 5-year survival >90 %; T3–T4 — total laryngectomy ± cervical lymph node dissection ± adjuvant chemoradiotherapy (cisplatin + 5-FU); laryngeal preservation protocols (induction chemo + RT) if possible |
| Recurrent laryngeal paralysis Vocal cord immobility |
Recurrent laryngeal nerve lesion (branch of vagus nerve X) → vocal cord immobility in paramedian or lateral position → breathy orDiplophonia, aphonia, dysphagia (aspiration); causes: thyroid or parathyroid surgery (per-operative lesion — 1–3 % after total thyroidectomy); left apical lung cancer (left recurrent laryngeal nerve loops around aortic arch — left apical tumor compresses nerve); aortic aneurysm; mediastinal tumor; idiopathic (viral — spontaneous recovery in 60–70 % at 12 months); carotid dissection | Laryngoscopy (visualization of vocal cord immobility); cervicothoracic CT scan (search for a compressive cause — pulmonary tumor, aortic aneurysm, mediastinal adenopathy) ± cervicomedial MRI; laryngeal EMG (prognosis for recovery); treatment: if idiopathic or post-viral paralysis — speech therapy + expectant management for 12 months (60–70% spontaneous recovery %); if persistence — medialization thyroplasty (Silastic implant to approximate the paralyzed cord) or intracordal injection (fat, calcium hydroxyapatite — Radiesse Voice); treatment of the cause if identifiable |
| Functional (psychogenic) dysphonia | Voice alteration without identifiable organic lesion of the vocal cords — laryngoscopy shows normal vocal cords or incomplete functional glottic closure; mechanisms: excessive laryngeal muscle tension (muscle tension dysphonia — MTD); psychogenic conversion (sudden complete aphonia often triggered by emotional stress — vocal cords close on swallowing but not on phonation); persistent falsetto voice in adolescent males (puberphonia — unconscious refusal to adopt the post-pubertal deep voice); vocal anxiety in voice professionals (stage fright) | Normal laryngoscopy (or functional spasm) — diagnosis of exclusion after ruling out organic causes; treatment: specialized vocal speech therapy (re-education of posture, breathing, laryngeal muscle tension — excellent results in MTD); psychological support if anxiety or trauma component; external laryngeal massage (reduction of peri-laryngeal muscle tension); puberphonia is treated in one to two speech therapy sessions in 95 % of cases |
| Other causes | Hypothyroidism (laryngeal myxedema — hoarse, deep voice); acromegaly (macroglossia + vocal cord thickening); laryngeal amyloidosis (vocal cord infiltration); recurrent laryngeal papillomatosis (HPV 6/11 — multiple proliferative benign lesions — repeated laser treatment — risk of malignant transformation <1 %); post-intubation granuloma (arytenoid trauma during oro-tracheal intubation); tobacco alone without cancer (chronic laryngitis + Reinke's edema — gelatinous filling of the subepithelial stroma of the vocal cords — very deep voice, especially in female smokers) | TSH + free T4 (hypothyroidism); IGF-1 + GH (acromegaly); laryngeal biopsy (amyloidosis, papillomatosis—HPV typing); laryngoscopy post-extubation if dysphonia after prolonged intubation; microlaryngeal surgery if symptomatic Reinke's edema (after smoking cessation—essential) |
Red Flags – Indications for Urgent Laryngoscopy
- Persistent dysphonia beyond 2-3 weeks without an obvious cause, especially in a smoker or former smoker — laryngoscopy is mandatory to rule out squamous cell carcinoma of the glottis (laryngeal cancer): early treatment of stage T1 disease → 5-year survival >90% %
- Dysphonia associated with progressive dysphagia, odynophagia, unilateral otalgia (referred ear pain), or hemoptysis — supraglottic extension or location to be excluded
- Firm, painless cervical adenopathy appearing in a smoker with dysphonia — cervical lymph node metastasis from a head and neck squamous cell carcinoma until proven otherwise
- Inspiratory stridor accompanying dysphonia—partial laryngeal obstruction requiring urgent evaluation (foreign body, epiglottitis, hematoma, obstructive tumor)
- Biphasic voice (vocal diplopia) of sudden onset - acute recurrent paralysis - emergency cervicothoracic CT scan to search for recurrent laryngeal nerve compression (lung cancer, aortic aneurysm)
- Post-thyroidectomy or cervical surgery dysphonia — systematic laryngoscopy within 48–72 hours postoperatively to document vocal cord mobility (legal reference) and guide early management
ℹ️
Visit Voice professionals (teachers, singers, actors, lawyers, speakers) constitute a high-risk population for benign vocal fold pathologies (nodules, polyps, muscle tension dysphonia) due to intensive and repetitive vocal use. A Vocal hygiene Strict adherence is fundamental for preventing these lesions: abundant hydration (2 L of water/day), avoiding whispering (higher vocal tension than normal speech), vocal rest after overuse, humidifying the ambient air in winter, avoiding repeated coughing and throat clearing, and limiting alcohol and coffee. Preventive speech therapy is recommended for voice professionals before the onset of symptoms, especially at the beginning of their careers.
Laryngeal emergencies
Dial 911 immediately in case of: stridor (high-pitched inspiratory wheezing) + dysphonia + respiratory distress — partial or complete laryngeal obstruction (foreign body, acute H. influenzae epiglottitis, laryngeal angioedema, post-traumatic laryngeal hematoma) - risk of asphyxia; ; acute epiglottitis In children or adults: high fever + severe odynophagia + hypersalivation + dysphonia + tripod position (sitting, leaning forward) — life-threatening emergency — do not examine the throat (risk of laryngeal spasm) — possible emergency intubation or tracheotomy.
See your doctor without delay if a Brutal, two-toned dysphonia appears after cervical or thyroid surgery — perioperative recurrent paralysis — ENT evaluation within 48 hours.
Consult at Clinique Omicron
Clinique Omicron physicians evaluate patients with dysphonia, prescribe first-line investigations (indirect laryngoscopy, TSH, reflux assessment), refer to ENT for nasofibroscopy and direct laryngoscopy if indicated, and coordinate speech therapy for benign vocal cord pathologies. Any dysphonia persisting beyond 3 weeks in a smoker is treated as a priority with rapid ENT referral. Consultations are available at our service points in Quebec as well as via telemedicine. To book an appointment, visit cliniqueomicron.ca.
The content of this page is provided for informational purposes only and does not substitute for the advice of a qualified healthcare professional. Any hoarseness lasting more than 2–3 weeks should be evaluated by a doctor, particularly in smokers.
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